At Boston Children’s Hospital, the quality of our care – and our inclusive hospital working environment – lies in the diversity of our people. With patients from local communities and 160 countries around the world, we’re committed to reflecting the spectrum of their cultures, while opening doors of opportunity for our team. Here, different talents pursue common goals. Voices are heard and ideas are shared. Join us, and discover how your unique contributions can change lives. Yours included.
The Director of Utilization Case Management responsibilities:
Developing & administering policies & procedures for UM of inpatient services.
Assisting in the development & implementation of procedures to track length of stay and level of care for admission.
Monitoring the process for clinical reviews & making recommendations to the VP of Business Operations on strategies to maximize revenue, prevent loss, contain costs, improve access and insure quality care.
Assuring compliance with Federal, State, JACHO, NCQA, & other regulatory agencies and internal standards.
Identifying risk management & quality of care issues across the continuum.
Maintaining relationships with departments & external providers & payers who provide services & ensures a responsive system for authorization of services and payment of claims; & assisting in negotiating access to care in targeted areas.
Acting as a liaison for departmental collaboration, communications, workflows, & problem resolution around operational utilization management functions.
Preparing reports on utilization patterns, expenditures by area & revenue stream, demographics of service delivery & trending of expenditures by program.
Establishing a process for tracking trends in payer policy & procedure updates & changes that effectively impact contractual adherence.
Training professional clinic & staff on current principals & standards of practice of UM, medical/surgical diagnosis & treatment coding and reimbursement.
Supervising staff: assigning, reviewing, & evaluating work; interviewing and hiring; counseling and disciplining, implementing systems. Preparing the budget.
Minimum of 6 years experience, with 2 years of experience in utilization review in a hospital or health care setting, preferred. Pediatric UM experience, preferred.
Knowledge of state & federal regulations applicable to treatment & reimbursement; utilization review procedures & techniques; medical & surgical diagnoses, procedures & treatments.
Ability to develop staff, establish priorities & meet deadlines.
Proficient in InterQual & Milliman criteria sets.
Advanced knowledge of software applications & strong analytic & data management & reporting skills.
The ability to communicate effectively & provide empathy.
Please note: During a public health emergency, individuals in this role may be expected to take on additional duties to respond to organizational needs.
Boston Children’s Hospital offers competitive compensation and unmatched benefits, including affordable health, vision and dental insurance, generous levels of time off, 403(b) Retirement Savings plan, Pension, Tuition Reimbursement, and discounted rates on T-passes (50% off). Discover your best.
Boston Children’s Hospital is an Equal Opportunity / Affirmative Action Employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, sex, sexual orientation, gender identity, protected veteran status or disability.
Internal Number: 59293BR
About Boston Children's Hospital (BCH)
Boston Children’s Hospital is dedicated to improving and advancing the health and well-being of children around the world through its life-changing work in clinical care, biomedical research, medical education and community engagement.Boston Children's is ranked the number one pediatric hospital in the nation by U.S. News and World Report. It is home to the world's largest pediatric research enterprise, and it is the leading recipient of pediatric research funding from the National Institutes of Health. It is the primary pediatric teaching hospital for Harvard Medical School. Boston Children’s treats more children with rare diseases and complex conditions than any other hospital.